HESI RN Case Study: Burns Test with 100% Verified Answers
Graded A+
1. Which action is included when a Level I disaster is All local hospitals
declared? prepare to receive
casualties.
2. Which action should the nurse implement to help Designate specific
these family members cope with this tragedy? family areas that
are staffed with
counselors.
3. EMS personnel triage clients, with multiple casualties Place a disaster
noted. Which action should the triage nurse imple- tag securely on
ment first? each victim.
4. Triage determines in what order a client is seen by -A client whose
a healthcare provider (HCP). Which of the following vital signs in-
clients would the nurse identify with a red tag? clude respirations
at 22 breaths/min
, pulse at 120
beats/min, and
blood pressure at
85/52 mmHg.
-A client with
a pulsating femur
wound.
-A client with full
thickness burns
over 50% of the
body.
5. Which triage category should the nurse assign to Priority 1, Color
James? Red.
6. The client has many physical, emotional, and psy- Establish and
chosocial needs. Which intervention is most impor- maintain an open
tant for the nurse to implement upon admission? airway.
7. The nurse should document which percentage of 45%
body surface?
8.
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, HESI RN Case Study: Burns Test with 100% Verified Answers
Graded A+
James grimaces in pain as the nurse assesses James' Partial thickness
red and blistered wounds that are affecting his epi- or second degree
dermis and dermis. Based on this assessment, which burns.
finding best describes the James' burns?
9. Based on the nurse's understanding of the Parkland The nurse admin-
Formula, which rate correctly describes the time the isters the first half
fluid is given to the client? of the fluid from
the time the burn
occurred over 8
hours, and the
second half over
the following 16
hours.
10. Which action should the nurse take? Inform the officer
that he must first
speak to James'
parents.
11. The police officer then asks to see James' ED medical Allow the police of-
record. Which action should the nurse take concern- ficer access to the
ing this request? requested medical
records.
12. Burn clients who surpass 20% Total Body Surface Assess the gastric
Area (TBSA) have massive shifts of fluid and elec- aspirate for pH and
trolytes from intravascular to extravascular spaces, blood the color of
which can lead to cardiovascular collapse. Which as- coffee grounds.
sessment relates most directly to a diagnosis of Curl-
ing's ulcer?
13. Fluid replacement is noted to be ideal if James pro- Urine is recorded
duces how much output/hour? as hourly output of
30 mL/kg.
14. James is receiving an escharotomy to treat his burn "The HCP will
complications. Which information is accurate for the make an incision
nurse provide to James' parents? in James' leg to
2/6
Graded A+
1. Which action is included when a Level I disaster is All local hospitals
declared? prepare to receive
casualties.
2. Which action should the nurse implement to help Designate specific
these family members cope with this tragedy? family areas that
are staffed with
counselors.
3. EMS personnel triage clients, with multiple casualties Place a disaster
noted. Which action should the triage nurse imple- tag securely on
ment first? each victim.
4. Triage determines in what order a client is seen by -A client whose
a healthcare provider (HCP). Which of the following vital signs in-
clients would the nurse identify with a red tag? clude respirations
at 22 breaths/min
, pulse at 120
beats/min, and
blood pressure at
85/52 mmHg.
-A client with
a pulsating femur
wound.
-A client with full
thickness burns
over 50% of the
body.
5. Which triage category should the nurse assign to Priority 1, Color
James? Red.
6. The client has many physical, emotional, and psy- Establish and
chosocial needs. Which intervention is most impor- maintain an open
tant for the nurse to implement upon admission? airway.
7. The nurse should document which percentage of 45%
body surface?
8.
1/6
, HESI RN Case Study: Burns Test with 100% Verified Answers
Graded A+
James grimaces in pain as the nurse assesses James' Partial thickness
red and blistered wounds that are affecting his epi- or second degree
dermis and dermis. Based on this assessment, which burns.
finding best describes the James' burns?
9. Based on the nurse's understanding of the Parkland The nurse admin-
Formula, which rate correctly describes the time the isters the first half
fluid is given to the client? of the fluid from
the time the burn
occurred over 8
hours, and the
second half over
the following 16
hours.
10. Which action should the nurse take? Inform the officer
that he must first
speak to James'
parents.
11. The police officer then asks to see James' ED medical Allow the police of-
record. Which action should the nurse take concern- ficer access to the
ing this request? requested medical
records.
12. Burn clients who surpass 20% Total Body Surface Assess the gastric
Area (TBSA) have massive shifts of fluid and elec- aspirate for pH and
trolytes from intravascular to extravascular spaces, blood the color of
which can lead to cardiovascular collapse. Which as- coffee grounds.
sessment relates most directly to a diagnosis of Curl-
ing's ulcer?
13. Fluid replacement is noted to be ideal if James pro- Urine is recorded
duces how much output/hour? as hourly output of
30 mL/kg.
14. James is receiving an escharotomy to treat his burn "The HCP will
complications. Which information is accurate for the make an incision
nurse provide to James' parents? in James' leg to
2/6
